Changes in the intestinal microbiome of the preterm baby associated with stopping non-invasive pressure support: a prospective cohort study.

BACKGROUND: Intestinal dysbiosis is implicated in the pathogenesis of necrotising enterocolitis and late-onset sepsis in preterm babies. The provision of non-invasive positive pressure ventilation is a common clinical intervention in preterm babies, and may be hypothesised to adversely affect intestinal bacterial growth, through increased aerophagia and induction of a hyperoxic intestinal environment; however this relationship has not been previously well characterised. METHODOLOGY: In this prospectively recruited cohort study, high-throughput 16S rRNA gene sequencing was combined with contemporaneous clinical data collection, to assess within-subject changes in microbiome development around the time of transitioning from non-invasive positive pressure respiratory support to unsupported spontaneous breathing. RESULTS: In a group of 14 preterm infants, bacterial diversity was seen to increase by 0.34 units/week (inverse Simpson index) at the point of transitioning off non-invasive positive pressure respiratory support. Correspondingly, a significant increase in anaerobic genera (Bifidobacteria spp, Veillonella spp), and a non-significant fall in Enterobacteriaceae was also seen at this time. CONCLUSIONS: Provision of non-invasive positive pressure ventilation is associated with suppression of both diversity accrual and obligate anaerobic growth in the preterm intestine. This has clinical implications in view of the widespread use of non-invasive positive pressure ventilation in preterm neonatal care (and wider adult use), and demonstrates the need for potential strategies (eg, probiotic support; reduced aerophagia) to support the development of a healthy gut microbiome during this time.

Effect of telemonitoring on the rate of dropout during home non-invasive ventilation: a retrospective study using a home care provider database.

OBJECTIVES: Telemonitoring (TM) of home non-invasive ventilation (NIV) has been shown to facilitate home/outpatient therapy set-up. However, the impact of long-term TM on therapy dropouts, compliance and leak control has not yet been clearly determined. This study evaluated whether the NIV dropout rate was reduced by TM combined with remote patient support compared with a non-telemonitoring (NTM) pathway. DESIGN: Retrospective cohort study. SETTING: Data were obtained from all agencies of a single home care provider in France. PARTICIPANTS: Adults with chronic respiratory failure (n=659) who started nocturnal NIV between January 2017 and December 2019 and had ≥8 days of NIV therapy (51% male; mean age 68.5±13.8 years; 35.5% on long-term oxygen therapy) were included. The TM group included 275 patients who spent ≥80% of the follow-up using TM, and the NTM group included 384 patients who had 0 to ≤10 days of telemonitoring during follow-up. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the rate of NIV dropouts at 1 year (ie, treatment discontinuation, excluding deaths). Secondary outcomes included therapy compliance and leaks. RESULTS: 82 patients died during follow-up. Significantly fewer patients in the TM vs NTM group had dropped out of NIV therapy at 1 year (13% vs 34%; p<0.001). After adjustment for age, sex, NIV usage at 1-month follow-up and the main underlying respiratory disease, TM was significantly associated with a lower risk of dropout (HR 0.33, 95% CI 0.23 to 0.49; p<0.001). At 1, 4, 8 and 12 months, a greater proportion of patients in the TM vs NTM group had NIV usage of >4 hours/day and control of leaks. CONCLUSIONS: In patients starting home NIV, TM with home care provider first-line support was associated with a lower therapy dropout rate at 1 year, and better compliance and leak control, compared with standard follow-up.

Ventilator performances for non-invasive ventilation: a bench study.

INTRODUCTION: A wide range of recent ventilators, dedicated or not, is available for non-invasive ventilation (NIV) in respiratory or intensive care units (ICU). We conducted a bench study to compare their technical performances. METHODS: Ventilators, including five ICU ventilators with NIV mode on, two dedicated NIV ventilators and one transport ventilator, were evaluated on a test bench for NIV, consisting of a 3D manikin head connected to an ASL 5000 lung model via a non-vented mask. Ventilators were tested according to three simulated lung profiles (normal, obstructive, restrictive), three levels of simulated air leakage (0, 15, 30 L/min), two levels of pressure support (8, 14 cmH2O) and two respiratory rates (15, 25 cycles/min). RESULTS: The global median Asynchrony Index (AI) was higher with ICU ventilators than with dedicated NIV ventilators (4% (0; 76) vs 0% (0; 15), respectively; p<0.05) and different between all ventilators (p<0.001). The AI was higher with ICU ventilators for the normal and restrictive profiles (p<0.01) and not different between ventilators for the obstructive profile. Auto-triggering represented 43% of all patient-ventilator asynchrony. Triggering delay, cycling delay, inspiratory pressure-time product, pressure rise time and pressure at mask were different between all ventilators (p<0.01). Dedicated NIV ventilators induced a lower pressure-time product than ICU and transport ventilators (p<0.01). There was no difference between ventilators for minute ventilation and peak flow. CONCLUSION: Despite the integration of NIV algorithms, most recent ICU ventilators appear to be less efficient than dedicated NIV ventilators. Technical performances could change, however, according to the underlying respiratory disease and the level of air leakage.

Noninvasive Respiratory Support in Acute Respiratory Distress Syndrome.

Noninvasive respiratory supports have been successfully used as an alternative to endotracheal intubation especially in patients with a milder degree of hypoxemia. In patients with acute respiratory distress syndrome (ARDS), the main goals of noninvasive oxygenation strategies are to improve oxygenation, unload the respiratory muscles, and relieve dyspnea. On the other hand, recent studies have suggested that spontaneous breathing could represent an additional mechanism of lung injury, especially in the more severe forms. The aim of this review is to describe the role of different noninvasive respiratory supports in ARDS, to optimize its use in clinical practice.

Comparison of noninvasive and intermittent positive pressure ventilation in treating extremely premature and extremely low birth weight infants.

OBJECTIVE: We compared the application value of noninvasive positive pressure ventilation (NIPPV) and intermittent positive pressure ventilation (IPPV) in the treatment of very premature infants and extremely low birth weight infants. METHODS: Multivariate logistic regression analysis was used to identify factors influencing the transition from noninvasive to invasive ventilation in this infant cohort. RESULTS: Among extremely preterm infants, 83.3% with gestational age <25 weeks transitioned from noninvasive to invasive ventilation, as did 80.6% of those with birth weight <1000 grams. Multivariate analysis indicated that gestational age <25 weeks, birth weight <1000 grams, and Apgar score ≤7 were significant factors affecting the likelihood of transitioning to invasive ventilation. The survival rate at discharge was 94% for the NIPPV group compared with 89% for the IPPV group. The NIPPV group demonstrated significantly lower rates of complications, shorter weaning times, and reduced lengths of hospital stay compared with the IPPV group. CONCLUSIONS: Both NIPPV and IPPV effectively improved oxygenation and ventilation in extremely preterm infants. However, NIPPV showed significant advantages in reducing complications, shortening weaning time, and decreasing the hospital stay duration. Prioritizing the use of NIPPV may enhance treatment outcomes and survival quality, providing evidence-based support for clinical practice.

Performance of newly developed add-on devices on aerosol delivery in noninvasive ventilated subjects.

Background: Several techniques had been developed to generate aerosolized medications during noninvasive ventilation (NIV) using variable inhalation methods. This study hypothesized that large spacers were more efficient significantly than small spacers and adapters during NIV. Objective: The main objective of this study was to compare the performance of newly developed spacers with standard T-piece in NIV chronic obstructive pulmonary disease (COPD) subjects. Methods: Sixty COPD subjects requiring NIV were included in this study. A dual-limb circuit was used, and the mode of ventilator was set in spontaneous volume-controlled mode. Dual-limb ventilation circuit, consists of inspiratory-limb and expiratory-limb, is pressure and volume controlled in response to subject expiration providing relatively high resistance to expiratory flow. Two experimental sets were evaluated: the first was introducing two preliminary pressurized metered-dose inhalers (pMDI) puffs before the nebulization of 1 ml of a respirable solution of salbutamol by vibrating mesh nebulizer (VMN) using Minimhal and Combihaler. The second was to only nebulize 1 ml of salbutamol respirable solution by VMN using Combihaler, Minimhal, and standard T-piece. Two urine samples were collected after aerosol delivery: urine sample after 30 min. (USAL0.5) as an indicator of lung deposition and all urine pooled 24 h (USAL24) post-inhalation as an indicator of systemic absorption. The amount of salbutamol extracted from urine samples was assayed by high-performance liquid chromatography. Results: Minimhal + pMDI + VMN delivered a higher percentage of salbutamol 30 min post-inhalation than Minimhal + VMN (p < 0.001). Also, Combihaler + pMDI + VMN delivered a higher percentage of salbutamol 30 min post-inhalation than Combihaler + VMN (p < 0.001). Combihaler + VMN delivered a higher percentage of salbutamol 30 min and 24 h post-inhalation than both Minimhal + VMN and T-piece + VMN (p < 0.001). Standard T-piece delivered the lowest aerosol amount delivered to the lung compared to both spacers (p < 0.05). Conclusions: Introducing two pMDI puffs significantly improved aerosol delivery by both spacers. Combihaler significantly improves aerosol delivery more than Minimhal.

Non-invasive positive pressure ventilation for acute asthma in children.

BACKGROUND: Asthma is one of the most common reasons for hospital admission among children, with significant economic burden and impact on quality of life. Non-invasive positive pressure ventilation (NPPV) is increasingly used in the care of children with acute asthma, although the evidence supporting it is weak, and clinical guidelines do not offer any recommendations on its routine use. However, NPPV might be an effective way to improve outcomes for some children with asthma. A previous review did not demonstrate a clear benefit, but was limited by few studies with small sample sizes. This is an update of the previous review. OBJECTIVES: To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children (< 18 years) with acute asthma. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, and Embase. We also conducted a search of ClinicalTrials.gov and the WHO ICTRP. We searched all databases from their inception to March 2023, with no restrictions on language of publication. SELECTION CRITERIA: We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children hospitalised for acute asthma exacerbations. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. MAIN RESULTS: We included three RCTs randomising 60 children with acute asthma to NPPV and 60 children to control. All included trials assessed the effects of bilevel positive airway pressure (BiPAP) for acute asthma in a paediatric intensive care unit (PICU) setting. None of the trials used continuous positive airway pressure (CPAP). The controls received standard care. The median age of children ranged from three to six years, and asthma severity ranged from moderate to severe. Our primary outcome measures were all-cause mortality, serious adverse events, and asthma symptom score. Secondary outcomes were non-serious adverse events, health-related quality of life, arterial blood gases and pH, pneumonia, cost, and PICU length of stay. None of the trials reported any deaths or serious adverse events (except one trial that reported intubation rate). Two trials reported asthma symptom score, each demonstrating reductions in asthma symptoms in the BiPAP group. In one trial, the asthma symptom score was (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03; 19 children) lower in the BiPAP group. In the other trial, a cross-over trial, BiPAP was associated with a lower mean asthma symptom score (MD -3.7; 16 children; very low certainty evidence) before cross-over, but investigators did not report a standard deviation, and it could not be estimated from the first phase of the trial before cross-over. The reduction in both trials was above our predefined minimal important difference. Overall, NPPV with standard care may reduce asthma symptom score compared to standard care alone, but the evidence is very uncertain. The only reported serious adverse event was intubation rate in one trial. The trial had an intubation rate of 40% and showed that BiPAP may result in a large reduction in intubation rate (risk ratio 0.47, 95% CI 0.23 to 0.95; 78 children), but the evidence is very uncertain. Post hoc analysis showed that BiPAP may result in a slight decrease in length of PICU stay (MD -0.87 day, 95% CI -1.52 to -0.22; 100 children), but the evidence is very uncertain. Meta-analysis or Trial Sequential Analysis was not possible because of insufficient reporting and different scoring systems. All three trials had high risk of bias with serious imprecision of results, leading to very low certainty of evidence. AUTHORS' CONCLUSIONS: The currently available evidence for NNPV is uncertain. NPPV may lead to an improvement in asthma symptom score, decreased intubation rate, and slightly shorter PICU stay; however, the evidence is of very low certainty. Larger RCTs with low risk of bias are warranted.

Role of Heart Rate, Acidosis, Consciousness, Oxygenation, and Respiratory Rate Score in Predicting Outcomes of Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease Patients.

BACKGROUND: In patients with chronic obstructive pulmonary disease (COPD), early detection of noninvasive ventilation (NIV) failure is a promising technique for decreasing mortality. The objective of this study was to evaluate the efficacy of heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) score in predicting NIV outcome in COPD-associated respiratory failure. METHODOLOGY: A prospective observational study was conducted on 100 COPD patients with acute respiratory failure who were initiated on NIV. HACOR score was calculated at the start of NIV and after 1-2, 12, and 24 hours. NIV failure was defined as progression to invasive mechanical ventilation or death. NIV success was defined as liberation from NIV prior to hospital day seven and not meeting criteria for failure. RESULTS: In this study, 100 patients with COPD and respiratory failure were enrolled. Their mean age was 65.34 years [standard deviation (SD) 8.19]. Male patients were predominant (n = 81). Eighty-nine percent of patients were smokers, and the remaining had exposure to biomass fuel. At the initiation of NIV, the median HACOR score was 3 (interquartile: 2, 4). In 13% of patients, there was NIV failure. There were 17 (17%) patients whose HACOR score at initiation was ≥5. In patients with a HACOR score ≥5, the NIV failure rate was 76.4% and mortality was 41.1%. The area under the curve (AUC) for prediction of NIV failure by HACOR score at initiation was 0.980 (p-value < 0.05). CONCLUSION: The HACOR score had high sensitivity as well as specificity at initiation in the prediction of NIV failure. A higher HACOR score predicts a high chance of NIV failure. Obtaining the HACOR score at the bedside makes it convenient for assessing the efficacy of NIV in patients with COPD.

Noninvasive neurally-adjusted ventilatory assist in preterm infants: a systematic review and meta-analysis.

BACKGROUND: Noninvasive neurally-adjusted ventilatory assist (NIV-NAVA) improves patient-ventilator synchrony and may reduce treatment failure in preterm infants compared with nasal continuous positive airway pressure (NCPAP) and noninvasive positive-pressure ventilation (NIPPV). We conducted a systematic review and meta-analysis to assess the effects of NIV-NAVA in preterm infants with respiratory distress. METHODS: Four investigators independently assessed the eligibility of studies in CENTRAL, CINAHL, ClinicalTrials.gov, Embase, MEDLINE, PubMed, and WHO ICTRP databases, and extracted data. The included studies were randomized controlled trials (RCTs) comparing NIV-NAVA with other noninvasive ventilation modalities in preterm infants. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The objective of the meta-analysis was to compare NIV-NAVA vs CPAP/NIPPV as a primary mode post extubation. RESULTS: Five RCTs which examined 279 preterm infants were included. In the subgroup of post-extubation respiratory support, NIV-NAVA decreased treatment failure compared with NCPAP/NIPPV (risk ratio 0.29; 95% confidence interval [0.10, 0.81], 2 RCTs, 96 infants, low certainty of the evidence). NIV-NAVA did not significantly reduce the risk of treatment failure in the subgroup of primary respiratory support (very low certainty of the evidence). There were no significant differences in secondary outcomes with low to very low certainty of evidence. CONCLUSIONS: In a small cohort with low certainty of evidence, NIV-NAVA may prevent reintubation in preterm infants. Further large-scale RCTs are needed to determine the effects and safety of NIV-NAVA in preterm infants.

Effect of Sitting Baduanjin exercise on early rehabilitation of sepsis patients with non-invasive ventilation : a randomized controlled trial.

BACKGROUND: For patients with sepsis receiving non-invasive ventilation (NIV), early rehabilitation is crucial. The Sitting Baduanjin (SBE) is an efficient early rehabilitation exercise suitable for bed patients. There is no consensus about the effect of SBE on the early rehabilitation of septic patients with NIV. This study focused on how the SBE affected the early rehabilitation of sepsis patients with NIV. METHODS: 96 sepsis patients with NIV were randomly assigned to either an Baduanjin group that received the SBE based on the routine rehabilitation exercise (n = 48) or a control group (n = 48) that received routine rehabilitation exercise. The primary outcome was the Medical Research Council(MRC)score, and the Barthel Index score, the duration of NIV, length of ICU stay, length of total stay, hospitalization expense as secondary outcomes. RESULTS: A total of 245 sepsis patients were screened, with 96 randomly assigned. The study was completed by 90 patients out of the 96 participants.Results revealed that the MRC score increased in both groups, but the improvement of muscle strength in Baduanjin group was more obvious, with statistical significance (p < 0.001).There was statistically significantly difference between the two groups in Barthel Index at the day of transfer out of ICU(P = 0.028).The patients in the Baduanjin group had an average reduction of 24.09 h in the duration of NIV and 3.35 days in total length of hospital stay compared with the control group (p < 0.05).Of note, the Baduanjin group had significantly reduction the total hospitalization expense. No serious adverse events occurred during the intervention period. CONCLUSIONS: In patients with sepsis, the SBE appears to improve muscle strength and activities of daily living (ADL), and lowed the duration of NIV, the length of the total stay, and the hospitalization expense. TRIAL REGISTRATION: The study registered on the Chinese Clinical Trial Registry ( www.chictr.org.cn ), Clinical Trials identifier ChiCTR1800015011 (28/02/2018).

"Comparison between high-flow nasal cannula (HFNC) therapy and noninvasive ventilation (NIV) in children with acute respiratory failure by bronchiolitis: a randomized controlled trial".

BACKGROUND: The objective of this study was to compare HFNC therapy to noninvasive ventilation (NIV/BiPAP) in children with bronchiolitis who developed respiratory failure. We hypothesized that HFNC therapy would not be inferior to NIV. METHODS: This was a noninferiority open-label randomized single-center clinical trial conducted at a tertiary Brazilian hospital. Children under 2 years of age with no chronic conditions admitted for bronchiolitis that progressed to mild to moderate respiratory distress (Wood-Downes-Férres score < 8) were randomized to either the HFNC group or NIV (BiPAP) group through sealed envelopes. Vital signs, FiO2, Wood-Downes-Férres score and HFNC/NIV parameters were recorded up to 96 h after therapy initiation. Children who developed respiratory failure despite receiving initial therapy were intubated. Crossover was not allowed. The primary outcome analyzed was invasive mechanical ventilation requirement. The secondary outcomes were sedation usage, invasive mechanical ventilation duration, the PICU LOS, the hospital LOS, and mortality rate. RESULTS: A total of 126 patients were allocated to the NIV group (132 randomized and 6 excluded), and 126 were allocated to the HFNC group (136 randomized and 10 excluded). The median age was 2.5 (1-6) months in the NIV group and 3 (2-7) months in the HFNC group (p = 0,07). RSV was the most common virus isolated in both groups (72% vs. 71.4%, NIV and HFNC, respectively). Thirty-seven patients were intubated in the NIV group and 29 were intubated in the HFNC group (29% vs. 23%, p = 0.25). According to the Farrington-Manning test, with a noninferiority margin of 15%, the difference was 6.3% in favor of HFNC therapy (95% confidence interval: -4.5 to 17.1%, p < 0.0001). There was no significant difference in the PICU LOS or sedation duration. Sedation requirement, hospital LOS and invasive mechanical ventilation duration were lower in the HFNC group. CONCLUSION: HFNC therapy is noninferior to NIV in infants admitted with mild to moderate respiratory distress caused by bronchiolitis that progresses to respiratory failure. TRIAL REGISTRATION NUMBERS: U1111-1262-1740; RBR-104z966s. Registered 03/01/2023 (retrospectively registered). ReBEC: https://ensaiosclinicos.gov.br/rg/RBR-104z966s .

Initiation of noninvasive ventilation in patients with amyotrophic lateral sclerosis.

INTRODUCTION/AIMS: Noninvasive ventilation (NIV) has been shown to improve survival and symptom burden in patients with amyotrophic lateral sclerosis (ALS). However, limited data exist regarding the clinical and physiological parameters at the time of NIV initiation. This study aimed to describe the clinical characteristics and respiratory physiological markers in a cohort of ALS patients with chronic respiratory failure. METHODS: This is a single-center retrospective cohort study of patients with ALS assessed for NIV initiation between February 2012 and January 2021. NIV was initiated based on insurance eligibility criteria: daytime hypercapnia, defined by partial pressure of carbon dioxide (PaCO2) >45 mm Hg using diurnal transcutaneous CO2 (TcCO2) as a surrogate, a maximal inspiratory pressure (MIP) <60 cmH2O or forced vital capacity (FVC) <50% predicted normal. RESULTS: We identified 335 patients with ALS and chronic respiratory failure referred to an outpatient home ventilation clinic for NIV initiation. The mean age was 64 years ±11; 151 (45%) were female, 326 (97%) were white, and 100 (29%) had bulbar-onset ALS. At the time of NIV initiation, the mean FVC was 64% ± 19%, the mean MIP; 41 cmH2O ± 17, and diurnal TcCO2; 40 ± 6 mmHg. The most common reasons for NIV initiation were MIP <60 cmH2O (58%) and multiple concomitant indications (28%). Within 1 year of NIV initiation, 126 (37%) patients were deceased. DISCUSSION: We found that impairment in inspiratory force was the most common reason for NIV initiation and often preceded significant declines in FVC.

Noninvasive vs invasive respiratory support for patients with acute hypoxemic respiratory failure.

BACKGROUND: Noninvasive respiratory support modalities are common alternatives to mechanical ventilation in acute hypoxemic respiratory failure. However, studies historically compare noninvasive respiratory support to conventional oxygen rather than mechanical ventilation. In this study, we compared outcomes in patients with acute hypoxemic respiratory failure treated initially with noninvasive respiratory support to patients treated initially with invasive mechanical ventilation. METHODS: This is a retrospective observational cohort study between January 1, 2018 and December 31, 2019 at a large healthcare network in the United States. We used a validated phenotyping algorithm to classify adult patients (≥18 years) with eligible International Classification of Diseases codes into two cohorts: those treated initially with noninvasive respiratory support or those treated invasive mechanical ventilation only. The primary outcome was time-to-in-hospital death analyzed using an inverse probability of treatment weighted Cox model adjusted for potential confounders. Secondary outcomes included time-to-hospital discharge alive. A secondary analysis was conducted to examine potential differences between noninvasive positive pressure ventilation and nasal high flow. RESULTS: During the study period, 3177 patients met inclusion criteria (40% invasive mechanical ventilation, 60% noninvasive respiratory support). Initial noninvasive respiratory support was not associated with a decreased hazard of in-hospital death (HR: 0.65, 95% CI: 0.35-1.2), but was associated with an increased hazard of discharge alive (HR: 2.26, 95% CI: 1.92-2.67). In-hospital death varied between the nasal high flow (HR 3.27, 95% CI: 1.43-7.45) and noninvasive positive pressure ventilation (HR 0.52, 95% CI 0.25-1.07), but both were associated with increased likelihood of discharge alive (nasal high flow HR 2.12, 95 CI: 1.25-3.57; noninvasive positive pressure ventilation HR 2.29, 95% CI: 1.92-2.74). CONCLUSIONS: These data show that noninvasive respiratory support is not associated with reduced hazards of in-hospital death but is associated with hospital discharge alive.

[Application effect and influencing factors of early awake prone position in patients with mild-to-moderate acute respiratory distress syndrome].

OBJECTIVE: To investigate the application effect of early awake prone position in mild-to-moderate acute respiratory distress syndrome (ARDS) patients, and analyze the related factors affecting the prone position outcome. METHODS: A prospective cohort study was conducted. The mild-to-moderate ARDS patients admitted to the emergency department of Yingshang County People's Hospital from January 2020 to June 2023 were enrolled as the research subjects. According to the results of prone tolerance test, the patients were divided into awake prone position group and non-prone position group. All patients were given high flow nasal cannula (HFNC) according to the standard procedures. The patients in the awake prone position group received prone position treatment within 12 hours after admission, in addition to the standard treatment. This could be performed in several times, at least once a day, and at least 2 hours each time. In order to prolong the prone position as much as possible, the patients were allowed to move or keep a small angle side prone. The changes of oxygenation index (PaO2/FiO2) at 0, 24, 48, and 72 hours after admission, the rate of intensive care unit (ICU) transfer, the use rate and use time of non-invasive ventilation (NIV), the total hospital stay, and the daily prone position time and 2-hour ROX index [ratio of pulse oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) and respiratory rate (RR)] of prone position patients were recorded. The successful termination of HFNC was defined as the successful prone position, and the failure of prone position was defined as switching to NIV or transferring to ICU. Subgroup analysis was performed, and the binary multivariate Logistic regression analysis was used to screen the influencing factors of the early awake prone position outcome. RESULTS: A total of 107 patients were finally enrolled, with 61 in the awake prone position group and 46 in the non-prone position group. Both groups showed a gradual increase in PaO2/FiO2 with prolonged admission time. The PaO2/FiO2 at 24 hours after admission in the awake prone position group was significantly higher than that at 0 hour [mmHg (1 mmHg ≈ 0.133 kPa): 191.94±17.86 vs. 179.24±29.27, P < 0.05], while the difference in the non-prone position group was only statistically significant at 72 hours (mmHg: 198.24±17.99 vs. 181.24±16.62, P < 0.05). Furthermore, the PaO2/FiO2 at 48 hours and 72 hours after admission in the awake prone position group was significantly higher than that in the non-prone position group. The use rate of NIV in the awake prone position group was significantly lower than that in the non-prone position group [36.1% (22/61) vs. 56.5% (26/46), P < 0.05]; Kaplan-Meier curve analysis further confirmed that the patients in the awake prone position group used NIV later, and the cumulative rate of NIV usage was significantly lower than that in the non-prone position group (Log-Rank test: χ 2 = 5.402, P = 0.020). Compared with the non-prone position group, the ICU transfer rate in the awake prone position group was significantly lowered [11.5% (7/61) vs. 28.3% (13/46), P < 0.05], and the HFNC time, NIV time, and total hospital stay were significantly shortened [HFNC time (days): 5.71±1.45 vs. 7.24±3.36, NIV time (days): 3.27±1.28 vs. 4.40±1.47, total hospital stay (days): 11 (7, 13) vs. 14 (10, 19), all P < 0.05]. Of the 61 patients who underwent awake prone positioning, 39 were successful, and 22 failed. Compared with the successful group, the patients in the failure group had a higher body mass index [BMI (kg/m2): 26.61±4.70 vs. 22.91±5.50, P < 0.05], lower PaO2/FiO2, proportion of asymptomatic hypoxemia and 2-hour ROX index of prone position [PaO2/FiO2 (mmHg): 163.73±24.73 vs. 185.69±28.87, asymptomatic hypoxemia proportion: 18.2% (4/22) vs. 46.2% (18/39), 2-hour ROX index of prone position: 5.75±1.18 vs. 7.21±1.45, all P < 0.05], and shorter daily prone positioning time (hours: 5.87±2.85 vs. 8.05±1.99, P < 0.05). Binary multivariate Logistic regression analysis showed that all these factors were influencing factors for the outcome of awake prone positioning (all P < 0.05), among which BMI [odds ratio (OR) = 1.447, 95% confidence interval (95%CI) was 1.105-2.063] and non-asymptomatic hypoxemia (OR = 13.274, 95%CI was 1.548-117.390) were risk factors for failure of prone position, while PaO2/FiO2 (OR = 0.831, 95%CI was 0.770-0.907), daily prone positioning time (OR = 0.482, 95%CI was 0.236-0.924), and 2-hour ROX index of prone position (OR = 0.381, 95%CI was 0.169-0.861) were protective factors. CONCLUSIONS: Early awake prone positioning in patients with mild-to-moderate ARDS supported by HFNC is safe and feasible, reducing the use rate and duration of NIV, lowering the ICU transfer rate, and shortening the hospital stay. High BMI and non-asymptomatic hypoxemia are risk factors for failed prone position, while higher PaO2/FiO2 and the ROX index within 2 hours of prone position (the patient's good response to prone position), and prolonged daily prone position can improve the success rate of prone position.

[Evidence-based nursing practice for the prevention of nasal and facial pressure injuries in patients with non-invasive positive pressure ventilation].

OBJECTIVE: To investigate the evidence-based practice of prevention and care of nasal and facial pressure injuries in patients with non-invasive positive pressure ventilation (NPPV) using the knowledge to action framework (KTA), and to explore its effectiveness. METHODS: Using an evidence-based nursing approach, an evidence-based practice group was established to formulate a clinical problem, the literature from domestic and international databases were researched for relevant evidence, the evidence was introduced into clinical scenarios, an evidence-based practice plan was developed, and a strategy for applying the best evidence was constructed by conducting a baseline review of healthcare professionals and patients with NPPV, analyzing barriers and promoting factors, and making changes in clinical practice at the organizational level, the practitioner level, and the patient level. Purposive sampling method was used to select the healthcare staff of the cardiac surgical intensive care unit (CSICU) of the Shandong Provincial Hospital Affiliated to Shandong First Medical University, as well as the patients with NPPV admitted from October 1 to November 15, 2023 (pre-evidence-based practice) and November 16 to December 31 (post-evidence-based practice), as the subjects of the study. Through questionnaire analysis, the incidence of nasal and facial pressure injury of NPPV patients, the implementation rate of review indicators of medical staff, the score of the knowledge, belief and conduct of medical staff, and the compliance and comfort of patients before and after evidence-based practice were compared. RESULTS: A total of 52 medical staff were included, aged (28.54±6.50) years old, with 3.00 (1.00, 12.75) years of working experience; 2 doctoral degree holders (3.85%), 4 master degree holders (7.69%), 46 bachelor degree holders (88.46%); 2 with senior title (3.85%), 17 with intermediate title (32.69%), and 33 junior titles (63.46%). Fifty patient questionnaires were collected before and after evidence-based nursing practice; the differences between before and after evidence-based practice in terms of gender, age, body weight, duration of ventilator usage, 24-hour bleeding and total bleeding were not statistically significant and were comparable. Compared with the pre-evidence-based practice, after carrying out the corresponding evidence-based nursing practice, the incidence of nasal and facial pressure injuries of NPPV patients decreased from 16.00% (8/50) to 4.00% (2/50, P < 0.05), the total implementation rate of review indicators of medical staff increased from 79.73% to 94.08% (P < 0.01), and the total scores of knowledge, belief and conduct were significantly improved (141.96±13.88 vs. 114.65±19.72, P < 0.05), and compliance and comfort of patients were significantly improved (compliance score: 4.60±0.99 vs. 5.82±1.42, comfort score: 4.10±1.63 vs. 6.92±2.33, both P < 0.05). CONCLUSIONS: The application of an evidence-based nursing approach to obtain evidence related to the prevention of nasal and facial pressure injuries in patients with NPPV can be used to guide clinical practice, significantly reducing the incidence of nasal and facial pressure injuries in such patients, improving the implementation rate of review indicators and the knowledge, belief, and conduct scores of medical staff, and enhancing compliance and comfort of NPPV patients.

Prophylactic non-invasive positive pressure ventilation reduces complications and length of hospital stay after invasive thoracic procedures: a systematic review.

QUESTION: In patients undergoing invasive thoracic procedures, what are the effects of prophylactic non-invasive positive pressure ventilation (NIV)? DESIGN: Systematic review with meta-analysis of randomised trials. Methodological quality was assessed using the PEDro scale and the certainty of evidence with the GRADE approach. PARTICIPANTS: Patients undergoing invasive thoracic procedures. INTERVENTION: Continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). OUTCOME MEASURES: Length of hospital stay, postoperative pulmonary complications, need for tracheal intubation, mortality, hypoxaemia, pulmonary function and adverse events. Meta-analysis was performed for all outcomes. Subgroup analyses estimated the effects of CPAP and BIPAP independently. RESULTS: Sixteen trials with 1,814 participants were included. The average quality of the included studies was fair. Moderate certainty evidence indicated that NIV reduces postoperative pulmonary complications (RD -0.09, 95% CI -0.15 to -0.04) without increasing the rate of adverse events (RD 0.01, 95% CI -0.02 to 0.04). Low certainty evidence indicated that NIV reduces length of hospital stay (MD -1.4 days, 95% CI -2.2 to -0.5) compared with usual care. The effects on intubation and mortality rates were very close to no effect, indicating that NIV is safe. Subgroup analyses showed that the evidence for CPAP had more precise estimates that that for BiPAP. CONCLUSION: NIV reduces postoperative pulmonary complications and length of stay after invasive chest procedures without increasing the risk of adverse events. REGISTRATION: PROSPERO CRD42015019004.